Specialty Drug Reimbursement – Newsletter – April 2019 – Volume 19, Issue 4


CMS News

  • New HCPCS® C-Codes Effective April 1, 2019 Now Available
  • Quarterly ASP (Average Sales Price) Pricing File Revised for April 2019
  • April 2019 NOC (Not Otherwise Classified) Pricing File
  • Hospital OPPS (Outpatient Prospective Payment System) Update

Drug Reimbursement Code Price Updates


  • New Clinical and Billing Information

Software Updates

  • Prioritize your Code Level Pricing


Large Price Changes:

We identify and report on the codes with the most substantial pricing increases or decreases each month and detail the rationale for the change.

Of the 59 AWP Drug Code Price changes this month, 15 (25%) were price decreases. The table in the Drug Reimbursement Code Price Updates section includes all AWP drug Code Price changes for this month. Please note:  These numbers represent AWP Code Price changes only. See below for examples of codes with significant price changes this month.



Price Decreases:

  • J2765 Injection, metoclopramide HCl, up to 10 mg 58%
  • J0637 Injection, caspofungin acetate, 5 mg 28%
  • J2800 Injection, methocarbamol, up to 10 mL 23%

Price Increases:

  • J7609 Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg (Code Price is for active ingredient only and does not include compounding cost) 45%
  • J3360 Injection, diazepam, up to 5 mg 42%
  • J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg (Code reinstated effective 4/1/2008) 31%


CMS News:

CMS (Centers for Medicare & Medicaid Services) created 8 new HCPCS® C-Codes effective as of April 1, 2019 for Medicare’s Hospital OPPS (Outpatient Prospective Payment System) billing. All new codes have been added to ReimbursementCodes.com. The following is a list of all new C-Codes with brand names listed (if applicable):

C9040– Injection, fremanezumab-vfrm, 1mg (Ajovy)

C9041– Injection, coagulation factor Xa (recombinant), inactivated (andexxa), 10 mg (Andexxa)

C9042– Injection, bendamustine hcl (belrapzo), 1 mg (Belrapzo)

C9043– Injection, levoleucovorin, 1 mg (Khapzory)

C9044– Injection, cemiplimab-rwlc, 1 mg (Libtayo)

C9045– Injection, moxetumomab pasudotox-tdfk, 0.01 mg (Lumoxiti)

C9046– Cocaine hydrochloride nasal solution for topical administration, 1 mg (Goprelto)

C9141– Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi), 1 i.u. (Jivi)


Quarterly ASP (Average Sales Price) Pricing File Revised for April 2019:

CMS recently provided notification that the following quarters had revisions to the ASP pricing file. Please note:Code(s) with revisions are noted in parenthesis.

July 2018 ASP Pricing File (Codes: J1561, J2790)

October 2018 ASP Pricing File (Codes: J0636, J1170, J1626, J2360, J2790, J3489, J7316, J7682

As per CMS, “the payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufacturers. The quarter to quarter price changes are generally the result of updated data from the manufacturers of these drugs.”

Our data files and website have incorporated these changes. As a reminder, we display the most recent revised rate on the Medicare Allowable tab on the pricing screen. To view previous Medicare Allowable rates for a quarter (if revised), click on the appropriate Effective Date on the same screen. Please Note:ASP rate revisions are retroactive to the beginning of the quarter.

April 2019 NOC (Not Otherwise Classified) Pricing File 

CMS released the April 1, 2019 NOC Pricing file.

To view the NOC pricing file on the website, search on a NOC (Not Otherwise Classified) code, product or NDC and click on the link “Listing of CMS ASP+6% rates for NOCs” under Additional Information on the left side of the screen.

Hospital OPPS (Outpatient Prospective Payment System) Update:

If billing under the Hospital OPPS (Outpatient Prospective Payment System) the April 1, 2019 – June 30, 2019 APC rates are now available on the Pricing tab under APC. The APC tab will also provide you with the APC and Status Indicator (SI), if established. Note: The only addition to the file is the Bendamustine HCl product by Eagle.


This month, during our review of the 3079 Reimbursement HCPCS/CPT® Codes in our system, we identified 59 Drug Codes that required a recalculation of their AWP Code Price. Log in to www.ReimbursementCodes.com to view the pricing updates for these codes.

90283 C9043 J0834 J3360 J9266
90284 C9044 J1095 J3420 J9267
A4215 C9045 J1327 J3489 Q4104
A4245 C9046 J1560 J7186 Q4105
A4353 C9141 J1561 J7194 Q4108
A4385 C9353 J1572 J7500 Q4110
B4153 C9356 J1942 J7609 Q4114
B4158 C9363 J2186 J7611 Q4137
C9035 J0153 J2469 J9027 Q4176
C9040 J0586 J2507 J9171 S0080
C9041 J0604 J2765 J9201 S0117
C9042 J0637 J2800 J9206


As new drugs come to market we review them for possible inclusion in our database. When a new drug is added to the database, we develop detailed clinical and billing information for the drug if appropriate.

During the past month, our review identified one new drug which needed to be added to our database. Our review of existing drugs in our database with clinical and billing information already assigned identified three drugs that required updating.


CABLIVI® (caplacizumab-yhdp) for injection, for intravenous or subcutaneous use –by Ablynx N.V  

INFUGEM (gemcitabine in sodium chloride injection), for intravenous use –by Sun Pharmaceuticals


DUPIXENT® (dupilumab) injection, for subcutaneous use-by Regeneron Pharmaceuticals, Inc.

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration

AIMOVIG™ (erenumab-aooe) injection, for subcutaneous useby Amgen Inc

  • ICD-10CM Codes

ZYKADIA™ (ceritinib) capsules for oral use by Novartis Pharmaceuticals Corporation

  • Indications & Usage, ICD-10CM Codes, and Dosage & Administration


Quick Price Change and Crosswalk Addition Reference

To quickly review price changes and crosswalk updates don’t forget to use the alert tab.  Click the Bell on the left-hand side of your screen, this will bring up all the codes with WAC, AWP and crosswalk additions, as well as important changes to specific codes to be aware of. This can be used as an easy reference to keep you up to date on the latest pricing changes.

One such update effective this month is the refinement to J1560’s code description, for more information regarding this, please refer to the section entitled Important Update for HCPCS Code J1560 above.


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